NURSE PROTOCOL FOR - GACHD



NURSE PROTOCOL FOR

OTITIS EXTERNA

DEFINITION Inflammation of the external auditory canal and auricle caused by a variety of infectious agents.

ETIOLOGY The most common cause of otitis externa is accumulation of water in the ear, leading to maceration and desquamation of the lining and conversion of the pH from acid to alkaline (e.g., swimming or frequent showers). It also may be initiated by trauma from scratching (fingernail or cotton-tipped applicator) or poorly-fitting earplugs for swimming. It may also accompany the chronic drainage from a perforated eardrum.

NOTE: An infant or child less than 2 years of age must strongly be suspected of having primary otitis media with secondary otitis externa.

The most common causative agents are Pseudomonas species and fungi, such as Candida albicans.

SUBJECTIVE 1. Pain and itching in ear(s).

2. Purulent discharge from ear.

3. Occasionally, decrease in hearing, or a sensation of obstruction in the ear(s).

OBJECTIVE 1. Pain aggravated by movement of the pinna tragus (the most common finding).

2. Ear canal may be swollen and erythematous. The client may be resistant to any attempt to insert an ear speculum.

3. Debris and exudate may be seen in the canal; the drum may be impossible to visualize.

4. Pre-auricular and/or post-auricular lymph nodes may be enlarged.

5. Swelling or pain over the mastoid should not be observed in uncomplicated otitis externa.

ASSESSMENT Otitis externa

PLAN DIAGNOSTIC STUDIES

NOTE: Tympanogram is contraindicated due to pain and need to avoid pressure.

THERAPEUTIC

Therapy centers around the basic principles of: local cleaning of debris and drainage of infection; restoration of the normal acidic protective barrier; judicious use of appropriate local and/or systemic antibiotics; and client education to prevent recurrent infection.

PHARMACOLOGIC

NOTE: Desquamated epithelium and moist cerumen may need to be removed by gentle irrigation before treatment.

1. For those patients with an intact tympanic membrane:

Cortisporin otic solution (not the suspension), instill

3 drops in affected ear canal 3-4 times a day for 10 days

OR

Children >1 year of age, Cipro HC otic suspension, 3 drops in the affected ear canal twice daily for 7 days.

2. The head should lie with the affected ear upward for medication instillation, and stay in that position for 1- 5 minutes to facilitate penetration of the drops into the ear canal.

3. May take age-appropriate doses of acetaminophen or ibuprofen for pain.

NON-PHARMACOLOGIC

Preventing external otitis may be necessary for individuals susceptible to recurrences, especially children who swim. The most effective prophylaxis is to place ethyl alcohol 70% 1:1 solution with acetic acid 2% (household white vinegar) in the ear canal immediately after swimming or bathing.

CLIENT EDUCATION/COUNSELING

1. Counseling is provided regarding the causes of otitis externa, administration of ear drops, and signs and symptoms which indicate the need for further evaluation.

2. Swimming, particularly during the acute phase, should be avoided. Bathing should be done in such a way as to keep the head out of the water, to avoid introducing soapy water and dirt into the ear canal.

3. Keep fingers and instruments (e.g., cotton swabs) out of the ear canals. There is no need to clean canals with swabs.

REFERRAL

1. Severe pain, fever or swelling of canal extensive enough to prevent instillation of drops. A cotton wick may be required.

2. Cellulitis of ear or surrounding tissue.

3. Clients with diabetes or other conditions predisposing them to more severe infection.

4. Failure to respond to treatment in 5-7 days.

5. More than one recurrence.

6. History or evidence of local sensitivity to neomycin in ear drops.

7. Tympanic membrane is perforated or not intact.

REFERENCES

1. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, (April 24, 2007).

2. Laurence Finberg and Ronald Kleinman, Saunders Manual of Pediatric Practice, 2nd ed., W. B. Saunders, 2002. (Current)

3. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current)

4. William W. Hay et al., Current Pediatric Diagnosis and Treatment, 16th ed., McGraw Hill, 2003. (Current)

5. Ferri, Ferri’s Clinical Advisor: Instant Dx and Rx, Mosby, 2007.

6. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, p. 2830.

7. Uphold and Graham, Clinical Guidelines in Family Practice, 4th ed., 2003, pp. 350-351. (Current)

8. Morgan Bernius and Donna Perlin, Pediatric Ear, Nose and Throat Emergencies, Pediatric Clinics of North America 2006, Volume 53, pp 195-214.

NURSE PROTOCOL

ACUTE OTITIS MEDIA

DEFINITION Presence of purulent fluid in the middle ear in association with signs and symptoms of acute local or systemic illness. Other terms

synonymous with acute otitis media (OM) include: suppurative

otitis media, acute bacterial otitis media, and purulent otitis media.

Occurs most frequently in winter months in children or = 3 months and < 40 kg: Initial treatment: |10 days |

|125 mg/5mL, 200mg/5mL, |80-90 mg/kg/day PO divided as either bid-tid | |

|250 mg/5mL, 400mg/5mL |Children > 40 kg: 250 mg-500 PO mg tid | |

| | | |

|Chewable: | | |

|125mg | | |

|200mg | | |

|250mg | | |

|400mg | | |

| |

|OR (only for penicillin allergic clients or clients for whom compliance with the 10-day/twice daily Amoxicillin |

|therapy is likely to be a problem) |

|> 6 months of age |See dosing charts below | |

| | | |

|Azithromycin |5 day regimen: 10mg/kg (maximum dose 500 mg/day) PO on day 1,| |

|100mg/5mL |then 5mg/kg (maximum dose 250 mg/day) PO days 2-5 | |

|200mg/5mL | | |

|250 mg capsule |3 day regimen: 10mg/kg (maximum dose 500mg/day) PO daily for | |

| |3 days | |

| | | |

| |Single dose regimen: 30mg/kg (maximum dose 1500mg) PO single| |

| |dose | |

| |Single dose regimen-higher incidence of nausea/vomiting | |

OTITIS MEDIA: (5-Day Regimen for Azithromycin)

Dosing Calculated on 10 mg/kg/day PO Day 1 and 5 mg/kg/day PO Days 2 to 5

| | | | | |

|Weight |100 mg/5 mL |200 mg/5 mL |Total mL per |Total mg per |

| | | |Treatment |Treatment |

| | | |Course |Course |

|Kg |Lbs |Day 1 |Day 2-5 |Day 1 |Day 2-5 | | |

|5 |11 |2.5 mL |1.25 mL | | |7.5 mL |150 mg |

| | |(½ tsp) |(¼ tsp) | | | | |

|10 |22 |5 mL (1 tsp) |2.5 mL | | |15 mL |300 mg |

| | | |(½ tsp) | | | | |

|20 |44 | | |5 mL |2.5 mL |15 mL |600 mg |

| | | | |(1 tsp) |(½ tsp) | | |

|30 |66 | | |7.5 mL |3.75 mL |22.5 mL |900 mg |

| | | | |(1½ tsp) |(¾ tsp) | | |

|40 |88 | | |10 mL |5 mL |30 mL |1200 mg |

| | | | |(2 tsp) |(1 tsp) | | |

|50 and |110 | | |12.5 mL |6.25 mL |37.5 mL |1500 mg |

|above |and | | |(2½ tsp) |(1¼ tsp) | | |

| |above | | | | | | |

OTITIS MEDIA: (3-Day Regimen for Azithromycin) Dosing Calculated on 10 mg/kg/day PO

| | | |Total mL per |Total mg per |

| | | |Treatment |Treatment |

|Weight |100mg/5mL |200mg/5mL |Course |Course |

|Kg |Lbs |Day 1-3 |Day 1-3 | | |

|5 |11 |2.5 mL | |7.5 mL |150 mg |

| | |(½ tsp) | | | |

|10 |22 |5 mL (1 tsp) | |15 mL |300 mg |

| | | | | | |

|20 |44 | |5 mL |15 mL |600 mg |

| | | |(1 tsp) | | |

|30 |66 | |7.5 mL |22.5 mL |900 mg |

| | | |(1½ tsp) | | |

|40 |88 | |10 mL |30 mL |1200 mg |

| | | |(2 tsp) | | |

|50 and |110 | |12.5 mL |37.5 mL |1500 mg |

|above |and | |(2½ tsp) | | |

| |above | | | | |

OTITIS MEDIA: (1-Day Regimen for Azithromycin) Dosing calculated on 30 mg/kg PO as a single dose

|Weight |200 mg/5 mL |Total mL per |Total mg per |

| | |Treatment |Treatment |

| | |Course |Course |

|Kg |Lbs. |Day 1 | | |

|5 |11 |3.75 mL |3.75 mL |150 mg |

| | |(3/4 tsp) | | |

|10 |22 |7.5 mL |7.5 mL |300 mg |

| | |(1 ½ tsp) | | |

|20 |44 |15 mL |15 mL |600 mg |

| | |(3 tsp) | | |

|30 |66 |22.5 mL |22.5 mL |900 mg |

| | |(4 ½ tsp) | | |

|40 |88 |30 mL |30 mL |1200 mg |

| | |(6 tsp) | | |

|50 and |110 |37.5 mL |37.5 mL |1500 mg |

|above |and |(7 ½ tsp) | | |

| |above | | | |

AMOXICILLIN/CLAVULANIC ACID

(Augmentin)

The following dosage chart provides guidelines for dosing at 90 mg/kg/day. If a more accurate dose is desired, the dose may be calculated individually by patient weight. NOTE: The American Academy of Pediatrics and the American Academy of Family Physicians recommend that a 10-day regimen be used for treatment of Acute Otitis Media in children younger than 6 years of age but that a duration of 5-7 days may be appropriate in those 6 years of age or older. Dosage should not exceed 1750 mg daily.

|WEIGHT |DOSE - 90 mg/kg/day |

| |(q12h 400 mg strength) |

|(Lb) |(kg) | 400 mg/5 mL |

| | |(400 mg tab) |

|10 |5 |3 mL q 12h (0.5 tablet q 12h) |

|20 |9 |5 mL q 12h (1 tablet q 12h) |

|30 |14 |8 mL q 12h (1.5 tablets q 12h) |

|40 |18 |10 mLq 12h (2 tablets q 12h) |

|60 |27 |10 mLq 12h (2 tablets q 12h) |

|80+ |36+ |10 mLq 12h (2 tablets q 12h) |

SUPPLIED:

• SUSPENSION: 50 mL, 75 mL, 100 mL and 150 mL.

o 400 mg Amoxicillin and 57 mg Clavulanic Acid/5 mL, Orange/Raspberry.

• CHEWABLE TABLET: 20s, 30s

o 400 mg Amoxicillin and 57 mg Clavulanic Acid, Cherry-banana.

NON-PHARMACOLOGIC

Modify risk factors to improve the odds of resolution:

1. Avoid passive smoking.

2. Control food and inhalant allergies.

3. Treat sinusitis.

4. Limit pacifier use after age one year.

5. Consider alternatives to group day care.

6. Practice prevention: encourage breast feeding; advise parents not to prop infant’s bottle and to elevate infant’s head when feeding; consider pneumococcal vaccine; consider influenza vaccine.

CLIENT EDUCATION/COUNSELING

1. Avoid unproven therapies, antihistamines, decongestants, homeopathy and naturopathy and folk remedies such as “sweet oil.”

2. Administer acetaminophen or ibuprofen for fever or pain discomfort. Refer to the acetaminophen and ibuprofen dosage chart listed in the Nurse Protocol for Fever.

3. Children with otitis media may return to school as soon as the fever is gone and they feel better. Otitis media is not contagious.

4. Give the complete amount of antibiotics.

5. Common side effects, storage of antibiotics (if refrigeration required), interactions, and when the antibiotic will expire and any other pertinent patient drug information.

6. Keep fingers and instruments (e.g., cotton swabs) out of the ear canals.

7. Importance of keeping follow-up appointments.

FOLLOW-UP

1. Return to clinic in 2-3 days if condition is not significantly improved.

2. Return visit several days after completion of antibiotic therapy or recheck in 2-3 weeks from initial visit. If the child is >15 months old and asymptomatic, visit may be scheduled for 4-6 weeks, if parents/client report that the infection has resolved.

REFERRAL

1. Clients who appear toxic, are not drinking and voiding, or are immunocompromised.

2. If condition is not significantly improved in 2-3 days, or fever and pain are not resolved after 48 hours of antibiotic therapy. (May consider amoxicillin/clavulinic acid for an additional 2-3 days before referral if the child is non-toxic.)

3. Signs and symptoms of meningitis: persistent lethargy, extreme irritability; stiff neck (unable to touch chest with chin). Substantial cough, rash, vomiting or other signs or symptoms that suggest illness beyond simple otitis media.

4. Infants less than 2 months of age.

5. Significant pain not relieved by acetaminophen or ibuprofen.

REFERENCES

1. Constance R. Uphold, and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003. (Current)

2. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, (April 24 , 2007).

3. S. Pelton, Otitis Media: Re-evaluation of diagnosis and treatment in an era of antimicrobial resistance, pneumococcal conjugate vaccine, and evolving morbidity, Pediatric Clinics of North America 2005, Volume 52, pp. 711-728.

4. Product Information Augmentin ES-600™, 2001. (Current)

5. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, Bethesda, MD, 2007, pp. 160-176,231-246, 310-316.

6. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003, p. 2344. (Current)

7. Pfizer Inc, Zithromax (azithromycin tablets and azithromycin for oral suspension), August 2007, .

8. Mathew J. Neff. AAP, AAFP release guidelines on diagnosis and management of AOM, American Family Physician, 69:2713, 2004. (Current)

NURSE PROTOCOL FOR

PEDICULOSIS CAPITIS

(Head Lice)

DEFINITION Infestation of the head by Pediculus humanus capitis. It is most

common in school-age white females.

ETIOLOGY The head louse attaches to hair. Females lay eggs embedded in water-insoluble glue that adheres the eggs to the hair shaft. Eggs hatch after 4 to 14 days. The lice ingest blood every few hours and can only survive 1 to 2 days away from a blood supply. Transmission occurs by direct contact, such as sharing hairbrushes, caps or clothing, or through close living quarters.

SUBJECTIVE 1. Itching.

2. Rash.

3. Nits or adult lice seen.

4. May give history of exposure to lice.

OBJECTIVE 1. Identification of lice or nits attached to head hair, eyebrows or eyelashes. Adult lice are hard to find, usually 7 days if live lice are seen. Re-treatment for recurrences is required in less than 1% of patients.

d. Treatment with NIX may temporarily exacerbate pruritus, erythema, or edema. Clients may experience mild transient burning/stinging, tingling, numbness, or scalp discomfort. If any reaction persists, refer client to a private care provider.

e. To prevent accidental ingestion, NIX should be stored in a locked area out of reach of children.

OR

2. Pyrethrins with piperonyl butoxide (e.g., nonprescription A-200, RID, Clear, Pronto) apply enough solution to completely wet hair, add water to lather, wait 10 minutes and rinse thoroughly with warm water. Use fine-toothed comb to remove lice and eggs from hair, shampoo hair to restore body and luster. Repeat application in 7-10 days. A-200 may be preferred because its benzyl alcohol base has pediculosidal activity.

OR

3. For resistance to permethrin and pyrethrins which is becoming increasingly common in the US:

Malathion (e.g., prescription Ovide). Do not use under age 6 yrs. Apply to dry hair. Allow to dry naturally; do not use an electric heat source. Eight (8) hours later, shampoo and rinse. Then comb with a fine-toothed metal comb. If necessary, repeat in 7-9 days.

4. For infestation of the eyelids or eyebrow, apply petrolatum ointment to eyelid margins or eyebrow bid for 8-10 days, followed by removal of nits.

5. Mild topical antipruritic/anti-inflammatory cream or ointment may be obtained over-the-counter for itching.

6. Evidence of secondary infection requires systemic antibiotic treatment. The patient should be assessed for impetigo treatment or physician referral.

NON-PHARMACOLOGIC

1. As an alternative to pediculocides, as prevention following exposure to head lice, or when previous treatments appear to have been unsuccessful:

a. To dry hair, apply a generous amount of olive oil, petroleum jelly, mayonnaise, any vegetable oil, or baby oil to the scalp. Massage well to distribute over all the hair.

b. Cover the head with a shower cap and leave the oil on overnight, or at least 8 hours.

c. In the morning, or after 8 hours, comb the hair with a regular comb to remove any tangles.

Comb with a nit comb through very small sections of hair. Be sure to wipe the comb often.

d. When all nits have been removed, shampoo hair. A second application of shampoo may be necessary to remove all of the oil.

e. Dry the hair as usual. Blow dryer temperatures can kill lice.

f. Check carefully for nits by parting off small sections of hair and looking under a very bright light.

g. If done properly, there is no need to repeat. All lice should be suffocated, and all nits removed.

OR

2. Remove nits with comb or tweezers. To aid in removal, soak hair with a 1:1 white vinegar:water solution. Cover the hair with a warm moist towel for 30-60 minutes, then comb. A product called “Step 2" which contains formic acid may be used to facilitate nit removal. Formic acid dissolves the cement that attaches the nit to the hair. It is applied to the hair after the pediculocide, left on for 10 minutes, then rinsed.

3. Adequate washing or dry-cleaning of clothes and linens used during the previous few days. Any item that cannot be washed or dry-cleaned should be stored in a plastic bag for two weeks.

4. Soak brushes, combs and hair accessories in hot water with pediculocide shampoo or alcohol for an hour.

5. Vacuum mattresses, pillows, upholstered furniture, and carpeting. Discard the vacuum cleaner bag. Fumigation of the home is not recommended.

CLIENT EDUCATION/COUNSELING

1. Contacts should be treated only if infestation is found.

2. Teach how to apply prescribed medication and decontaminate clothing and other articles.

3. Flush the eyes with water immediately if pediculocide gets in the eyes.

4. Avoid unnecessary re-treatment because of the toxic hazard.

5. Itching may persist for 1-2 weeks even after adequate treatment, and should not be considered a reason for reapplication of medication.

6. Educate about the person-to-person mode of transmission, and procedures to prevent transmission.

a. Do not share combs, brushes or head gear/coverings with other persons.

b. Hang coats where they do not touch those of other persons.

7. Assure that head lice infestation is a common problem in the school-age population and affects children of all socio-economic groups.

8. Instruct caregiver that child may return to daycare or school the next day after first treatment for head lice. It is not recommended that child be excluded from school based on the presence of nits.

9. Client may ask about the use of hot air to cure head lice. Only one article has studied this therapy. It evaluated six different methods of delivering hot air to the scalp. All methods demonstrated substantial egg destruction but only one method was highly effective against hatched lice and demonstrated a high long-term cure rate. This method requires a special device for delivering hot air to the scalp which is not yet commercially available. Using a simple hair dryer to expose the hair and scalp to hot air was not effective and should not be recommended.

FOLLOW-UP

1. Reevaluate in one week if symptoms persist.

2. Re-treatment may occasionally be necessary. Use an alternate regimen if not responding to treatment.

REFERRAL

Consult with physician regarding any question of management.

REFERENCES

1. Catherine E. Burns, et al., Pediatric Primary Care, A Handbook for Nurse Practitioners, 2nd ed., W.B. Saunders, Philadelphia, PA, 2000. (Current)

2. Thomas B. Fitzpatrick, et al., Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases, 4th ed., McGraw-Hill, New York, NY, 2001. (Current)

3. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, (April 24 , 2007).

4. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 3505-3510.

5. Constance R. Uphold, and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003, pp. 294-295. (Current)

6. American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 27th ed., 2006, p. 488. (Current)

7. Christine J. Ko & D. M. Elston, Pediculosis, Journal of American Academy of Dermatology, 50:1-12, 2004. (Current)

8. Georgia Department of Human Resources Division of Public Health, Children's Healthcare of Atlanta, & Georgia Association of School Nurses, Georgia School Health Resource Manual, 2004. (Current)

9. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 .

10. Laurie Barclay and Desiree Lie, Hot air may be an effective non-chemical treatment of head lice, Pediatrics, 2006, Volume 118, pp. 1962-1970.

NURSE PROTOCOL FOR

PHARYNGITIS

DEFINITION Inflammation of the pharynx, and surrounding lymph tissue

(tonsils).

ETIOLOGY Viral causes:

1. Rhinoviruses.

2. Adenoviruses.

3. Herpangina due to Coxsackie virus and echovirus.

4. Hand-foot-and-mouth disease due to Coxsackie virus.

5. Infectious mononucleosis caused by Epstein-Barr virus.

6. Human immunodeficiency virus (HIV).

Bacterial causes:

1. Group A beta-hemolytic streptococcus.

2. Neisseria gonorrhoeae.

3. Corynebacterium diphtheriae.

4. Streptococci of Lancefield Group C and G (often associated

with contaminated food).

5. Chlamydia trachomatis.

Other causes:

1. Mycoplasma pneumoniae.

2. Candida albicans.

3. Noninfectious causes:

a. Allergic rhinitis or post-nasal drip.

b. Mouth breathing.

c. Trauma from heat, alcohol, irritants such as marijuana, or sharp objects.

d. Subacute thyroiditis in females.

SUBJECTIVE Client may complain of:

1. Fever, headache and malaise, often accompanied

with sore throat and difficulty swallowing.

2. Small oral vesicles or ulcers on tonsils, pharynx, or posterior buccal mucus.

OBJECTIVE 1. Pharyngitis due to Group A beta-hemolytic streptococcus:

(Common in school-age children; uncommon if 101o F.

b. Erythema of tonsils and pharynx with white or yellow exudate.

c. Tender and enlarged anterior cervical lymph nodes are often present.

d. Abdominal pain, vomiting, and headache may occur, but upper respiratory symptoms suggest other causes of pharyngitis.

e. Improper antimicrobial treatment, can lead to serious suppurative (direct extension from pharynx) and nonsuppurative complications arising from immune responses to acute infections (rheumatic fever).

f. (with selected strains) A scarlatiniform rash – a blanching erythematous rash with a sandpaper texture that is diffusely distributed but is most prominent in the intertriginous areas.

2. Pharyngitis due to Corynebacterium diphtheriae:

a. Gray adherent membrane on the nasal mucosa, tonsils, uvula or pharynx.

b. Bleeding occurs when membrane is removed.

3. Pharyngitis due to Neisseria gonorrhoeae and Chlamydia trachomatis: (Seen in clients who practice orogenital sex. Consider sexual abuse if a child.)

Commonly presents as a chronic sore throat.

4. Pharyngitis due to Mycoplasma pneumoniae:

(Uncommon in children 27kg/adult: | |

| |500mg PO bid | |

| | | |

|OR | | |

| | | |

|Amoxicillin |Child > 3 months and | |

|125mg/5mL suspension |< 40 kg: 50mg/kg/day PO every 8 – 12 hours to |10 days |

|250mg/5mL suspension |a max of 750mg | |

|250 mg chewable tabs |500mg BID or TID | |

| | | |

|OR | | |

|Benzathine penicillin |Child < 27kg: |- Observe for 30 minutes after |

|(When compliance with oral med a concern) |600,000 units IM x 1 |injection, for possible anaphylaxis|

| | |- To reduce discomfort, bring |

| |Child >27kg/adult: |medication to room temperature |

| |1,200,000 units IM x 1 |before injecting |

| | | |

| | | |

| | | |

|OR | | |

|For penicillin-allergic children |Child: (EES) |10 days |

| |40 mg/kg/day PO | |

|Erythromycin ethyl-succinate (EES/Eryped) |2-4 divided doses | |

|200 mg/5mL suspension | | |

|400 mg/5mL suspension |Maximum dose in children for ethylsuccinate is| |

| | | |

| |3.2 gm/day PO | |

| | | |

|Erythromycin base |Adult: (E-mycin, Ery-Tab) | |

|(E-Mycin, Ery-Tab) |250 mg PO q 6 hours | |

|250 mg, 333 mg, 500 mg |OR | |

| |333 mg PO q 8 hours | |

| |OR | |

| |500 mg PO q 12 hours | |

| | | |

| |Severe infections may require increased | |

| |dosages. | |

| | | |

| |Maximum dose of 2 gm/day. If dosages exceed | |

| |1gm/day the q12 hour dosing is not | |

|OR |recommended. | |

| | | |

|Azithromycin (Zithromax) |Child > 2 years: 12 mg/kg/day PO as a single | |

|100mg/ 5mL suspension |dose to a max of 500mg |5 days |

|200mg/5mL suspension | | |

|250mg capsule | | |

| | | |

|OR | | |

|Cefdinir (Omnicef) |14mg/kg/day PO divided bid to a max of 600mg |10 days |

|300mg capsule |per day | |

|125mg/5mL suspension | |NOTE: Do not give to clients |

| | |allergic to penicillin. |

| | | |

|OR | | |

| | |10 days |

|Cefadroxil (Duricef) |30mg/kg PO as a single dose or divided into 2 | |

|250mg/5mL suspension |equal doses | |

|500mg/5mL suspension | |NOTE: Do not give to clients |

|500 mg capsule |Max dose 2 gm/day |allergic to penicillin. |

| | | |

| |Adult: 500mg PO bid | |

| | | |

CLIENT EDUCATION/COUNSELING

1. Seek health care immediately if the pain becomes more severe or if dyspnea develops, or if drooling, stiff neck, possible dehydration, difficulty swallowing, or inability to fully open the mouth occurs.

2. Increase fluid intake.

3. May use hard candy, lozenges, or warm saline to soothe throat.

4. Clients with streptococcal pharyngitis should not return to school or work until they have been on antibiotic therapy for a full 24 hours.

5. Will usually feel well within 24-48 hours, but it is important to take the full 5 or 10-day course of antibiotic to prevent complications, particularly rheumatic fever.

6. Common side effects of the antibiotic, storage, interactions, when the drug will expire and any other pertinent information.

7. Discard or sanitize old toothbrush. Sanitize toothbrush by rinsing with hydrogen peroxide or Listerine® after each use until the antibiotic course is completed. Get a new toothbrush after antibiotic course is completed.

8. Observe for and return if there is discolored urine, arthritis or failure to improve after 48 hours.

FOLLOW-UP

1. If no significant improvement in 3-4 days, client should return to health care provider.

2. Post-treatment throat cultures for clients with streptococcal pharyngitis if there is a suspicion of a strep carrier state (recurrent positive strep tests).

REFERRAL

1. Complications of streptococcal pharyngitis.

2. Recurrence of streptococcal pharyngitis.

3. Peritonsillar abscess.

4. Mononucleosis.

REFERENCES

1. Constance R. Uphold and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003. (Current)

2. Lexi-Drugs OnlineTM, “Lexi-Comp Database,”TM Lexi-Comp, Inc., Hudson, Ohio, 2007, (April 24 , 2007).

3. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current)

4. American Society of Health-Systems Pharmacists, American Hospital Formulary Services, 2007, pp. 103-104, 125-127,222-228, 231-246, 281-284, 306-309.

5. Robert Rakel, Conn’s Current Therapy, 57th ed., Eisevier, 2005.

6. Sarah Long et al., Principles and Practice of Pediatrics Infectious Disease, Churchill Livingston, 2003, p. 182. (Current)

7. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 .

8. Feder, H.M Jr., Gerber, M.A., Randolph, M.F., Shelmach, P.S., Kaplan, E.L., “Once-daily therapy for streptococcal pharyngitis with amoxicillin”, Pediatrics, Vol. 103, January 1999, pp. 47-51. (Current)

9. Michael Gerber, Diagnosis and treatment of pharyngitis in children, Pediatric Clinics of North America, 2005, Volume 52, pp 729-747.

10. H. Clegg, et al., Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial, Pediatric Infectious Disease Journal, 2006, Volume 25, pp 761-767.

NURSE PROTOCOL FOR

PINWORMS

DEFINITION A parasitic nematode causing infestation of the intestines and rectum. Up to 30% of children in the United States have pinworms. Pinworms are indigenous to the climate of the southern United States, usually affecting young children and their families. Adult worms are 5-10 mm long and live in the colon. Females deposit eggs on the perianal area, primarily at night, causing intense pruritis. Scratching contaminates the fingers and allows transmission back to the host or to contacts.

ETIOLOGY The nematode, Enterobius vermicularis.

SUBJECTIVE 1. May be asymptomatic.

2. Nocturnal perianal pruritus is the primary symptom.

3. Young females may experience genital irritation with vulvovaginitis and dysuria.

4. History of caretaker’s observation of worms in anal area at

night while child is sleeping.

5. Other symptoms may include anorexia, enuresis, insomnia, and grinding teeth during sleep.

OBJECTIVE 1. Diagnostic Criteria

a. Laboratory identification of eggs from perianal area:

Apply transparent adhesive tape to the perianal area to pick up any eggs; apply tape to a glass slide and examine under a low-power microscope. (Obtain specimens in the early morning before client bathes or defecates.)

OR

b. Observation of pinworm(s) during exam.

2. May have local irritation or secondary infection of scratched skin.

ASSESSMENT Pinworms

PLAN THERAPEUTIC

PHARMACOLOGIC

1. If not pregnant, lactating, taking carbamazepine, cimetidine, or phenytoin, or a child 6 mos.)

2. Avoid topical anesthetics (teething gels). They can cause profound numbness of the entire oral cavity and pharynx and suppress the gag reflex. They can also induce allergies to ‘caine’ anesthetics.

NON-PHARMACOLOGIC

1. Be patient and soothe the infant.

2. Offer a child Zwieback or hard toast. Offer an infant a teething ring of hard rubber or plastic, or a clean, cold, wet washcloth for chewing on.

PARENT EDUCATION/COUNSELING

1. Counsel about the above therapeutic measures.

2. Be sure that the infant/child does not chew on things that would break or splinter in the mouth.

REFERRAL

Eruption cysts or hematomas.

REFERENCES

1. William W. Hay et al, Current Pediatric Diagnosis and Treatment, 16th ed., McGraw-Hill, 2003. (Current)

2. Carol D. Berkowitz, Pediatrics: A Primary Care Approach, 2nd ed., W.B. Saunders, 2000, pp. 245-247. (Current)

3. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current)

NURSE PROTOCOL FOR THRUSH

(ORAL CANDIDIASIS)

DEFINITION Superficial fungal infection of the mouth, frequently occurring in healthy newborns. It is rare in older children and adults except those who are debilitated or receiving antibiotic or immuno-suppression therapy.

ETIOLOGY The causative organism is usually Candida albicans, which is acquired from the following sources:

1. In newborns, from mother’s vagina during birth.

2. Persons that may be debilitated and those receiving antibiotic therapy.

3. By contamination of caretaker’s hands or objects shared by babies.

4. Adult with vulvovaginal candidiasis, through contamination of her hands. (See protocol for vulvovaginal candidiasis.)

5. Infants/children with candidal diaper dermatitis, through contamination of hands.

SUBJECTIVE 1. Often no symptoms.

2. Creamy white patches in the mouth, may be curd-like in nature.

3. With extensive involvement, pain during feeding and swallowing.

4. May have history of recent steroid, antibiotic or chemotherapy treatment.

OBJECTIVE 1. White flaky coating or patches covering all or part of the tongue, gingiva, buccal mucosa and, occasionally, the lips. (Don’t confuse with milk curds left on the tongue after feeding.)

2. If patches are removed, they leave a painful, red bleeding lesion.

3. The patient may have candidal diaper dermatitis that needs treatment.

4. May have an inadequate oral intake because of mouth pain. Check for dehydration (uncommon).

ASSESSMENT Oral Candidiasis (Thrush)

PLAN DIAGNOSTIC STUDIES

Potassium hydroxide preparation of scrapings of lesions to detect budding yeast, with or without hyphae. (This study is usually not needed when typical lesions are present.)

THERAPEUTIC

PHARMACOLOGIC

1. Treatment of infant:

Nystatin (Mycostatin) oral suspension,100,000 units/mL, to use in a dosage of 200,000 units (2 mL) four (4) times a day for two weeks. The dose should be divided so that ½ is placed in each side of the mouth. The suspension should be retained in the mouth for as long as possible. One way to accomplish this is to apply a portion of the dose to two Q-tips and gently massage these Q-tips against the plaques.

Low birth-weight infants should receive a dose of 100,000 units (1 mL) four (4) times daily.

2. Treatment of nursing mother:

Nystatin (similar to Mycostatin) ointment applied to nipple and areola areas after each feeding

OR

Nystatin oral suspension 100,000units/mL; swab 1 mL on each breast nipple four times daily after feeding, for 2 weeks.

3. If diaper rash is present, treat according to Nurse Protocol for Diaper Dermatitis due to candidiasis.

CLIENT EDUCATION/COUNSELING

1. Continue treatment for two weeks, even if the mouth appears to have cleared before the fourteenth day.

2. Properly treated, thrush should not be a cause for weaning from the breast.

3. Breast-fed infants and their mothers are to be treated simultaneously.

4. Wash hands thoroughly before handling any baby.

5. Rubber/plastic nipples and pacifiers should be boiled for 10 minutes, or replaced after beginning treatment. Do not allow infants to share pacifiers or nipples.

REFERRAL

1. Failure to respond after two weeks of therapy.

2. Weight loss, or suspected dehydration.

3. Recurrent or resistant breast infections.

4. Persons with recurrent infections are to be evaluated for HIV infection.

REFERENCES

1. Ruth Lawrence, Breast-Feeding: A Guide for the Medical Profession, 5th ed., C.V. Mosby Co., 1998. (Current)

2. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current)

3. Carol D. Berkowitz, Pediatrics: A Primary Care Approach, 2nd ed., W.B. Saunders, 2000, pp. 213, 215, 230, 459. (Current)

4. American Society of Health-Systems Pharmacists, American Hospital Formulary Services, Bethesda, MD, 2007, p.3491-3494.

5. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 .

NURSE PROTOCOL FOR

TINEA PEDIS

DEFINITION Dermatophyte infections of the skin of the feet and toes.

ETIOLOGY Trichophyton rubrum is the most common pathogen.

Trichophyton mentagrophytes causes more inflammatory lesions.

The fungus is transmitted by direct contact with contaminated surfaces in moist areas such as swimming pools, community showers or baths and locker rooms. Tinea pedis occurs most frequently in adolescents and adults. Risk factors include sweaty feet and occlusive footwear.

SUBJECTIVE 1. May be asymptomatic.

2. Mild itching.

3. May have burning, stinging and other sensations.

OBJECTIVE 1. On the sole and heel: usually non-inflammatory scaling, occasionally with thickening and cracking of the skin. May have groups of vesicles or exfoliation of the skin. Foul odor is common.

2. Between the toes: scaling or fissuring, fine vesicles or pustules, maceration.

3. Potassium hydroxide (KOH) skin-scraping: hyphae demonstrated (more likely to find from dry scaly areas than from wet, macerated areas).

ASSESSMENT Tinea pedis

PLAN THERAPEUTIC

PHARMACOLOGIC

1. One of the following products. Continue treatment for 1-2 weeks after clinically cleared.

a. Over-the-counter products, applied bid for

2-4 weeks to the affected areas.

1) Miconazole (e.g., Micatin) 2% cream

OR

2) Clotrimazole (e.g., Lotrimin, Mycelex)

1% solution, cream or lotion

OR

3) Tolnaftate 1% (e.g., Tinactin)

OR

b. Prescription products

1) Ketoconazole 2% cream (e.g., Nizoral) - Apply once daily for 6 weeks.

2) Econazole 1% cream (e.g. Spectazole) - Apply once daily for 4-6 weeks.

2. Burrow’s solution may be used as a foot soak, 20-30 minutes bid, for lesions between the toes.

CLIENT EDUCATION/COUNSELING

1. Wear rubber or wooden sandals in community showers and locker rooms.

2. Wash the feet with a benzoyl peroxide bar after showering.

3. Carefully dry between the toes after bathing/showering. A hair dryer on low setting may be used after toweling dry.

4. Change socks frequently. Avoid occlusive footwear. Remove shoes and socks, when possible, to allow air circulation for feet and toes.

5. Apply dusting or drying powders as necessary. Using antifungal powders may prevent recurrence of infection.

6. Completion of therapy is important.

7. Avoid spreading the infection to others. Good hand-washing, thorough cleaning of bathrooms and avoidance of sharing bath towels and wash clothes may inhibit transmission.

FOLLOW-UP

Recheck in two weeks if not improved.

REFERRAL

1. No improvement after two weeks of treatment.

2. Severe infection, or secondary bacterial infection.

3. Extension of the disease to the nails.

REFERENCES

1. Lawrence M. Tierney, et al., Current Medical Diagnosis and Treatment, 42nd ed., McGraw-Hill, 2003. (Current)

2. Constance R. Uphold and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Gainesville, FL, 2003. (Current)

3. Jane A. Fox, Primary Health Care of Infants, Children and Adolescents, 2nd ed., Mosby-Year Book, 2002. (Current)

4. Thomas B. Fitzpatrick, et al., Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases, 4th ed., McGraw-Hill, New York, NY, 2001. (Current)

5. American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 27th ed., Elk Grove Village, IL, 2006.

6. Carol K. Takemoto et al., Pediatric Dosage Handbook, 2002-2003, 9th ed., Lexi-Comp, Inc., 2002. (Current)

7. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, Bethesda, MD, 2007, pp. 3465-3468, 3472-3475, 3494.

8. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 .

NURSE PROTOCOL FOR

UPPER RESPIRATORY INFECTION (URI)

(COMMON COLD)

DEFINITION An acute infection of the upper respiratory tract involving the nose, pharynx, sometimes the paranasal sinuses and, perhaps, the middle ears. It lasts several days. Since the activity of the viruses in the upper respiratory tract can impair local defense mechanisms, invasion by bacteria may occur and cause infections of the ears and sinuses.

ETIOLOGY Numerous viruses. In the U.S., peak incidences in children occur in early fall (when schools open), midwinter and early spring. Colds occur most commonly during the second and third years of life, and the average child has from three to eight infections per year. Malnutrition seems to increase susceptibility to colds.

SUBJECTIVE 1. General malaise.

2. Nasal stuffiness, nasal discharge, sneezing, cough.

3. Mild sore throat.

4. Watery eyes.

5. Decreased appetite, particularly in infants.

OBJECTIVE 1. Low-grade fever ( ................
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